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Bioterrorism Web Site Resources for Infectious Disease Clinicians and Epidemiologists

  1. Natalie E. Ferguson1,
  2. Lynn Steele5,
  3. Carol Y. Crawford1,
  4. Nathan L. Huebner3,6,
  5. Jamila C. Fonseka3,
  6. Jason C. Bonander4, and
  7. Matthew J. Kuehnert2
  1. 1Office of Health Communications, Atlanta, Georgia
  2. 2Division of Healthcare Quality Promotion, Atlanta, Georgia
  3. 3Bioterrorism Preparedness and Response Program, National Center for Infectious Diseases, Atlanta, Georgia
  4. 4Information Resources Management Office, Atlanta, Georgia
  5. 5Office of the Director, Office of Communications, Centers for Disease Control and Prevention, Atlanta, Georgia
  6. 6Northrop Grumman Mission Systems, Los Angeles, California
  1. Reprints or correspondence: Natalie Ferguson, Office of Health Communication, National Center for Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd., MS C-14, Atlanta, GA 30333 (nferguson{at}cdc.gov).
 
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Abstract

Finding bioterrorism-related information on the World Wide Web can be laborious. We hope to help readers find such information more easily by summarizing essential information in a consistent framework. A panel of 7 Centers for Disease Control and Prevention reviewers identified Web sites and evaluated them for sponsorship, mission, content usefulness, online ease of use, and adherence to commonly accepted quality criteria. Of >100 potential sites identified, 81 were chosen for target content of interest, and 43 were selected for inclusion. The results were classified into general purpose/portal sites; biological agent information; laboratory, infection control, epidemiology, and mental health information; and emergency contact sources, news and updates, event preparedness resources, information for first-responder settings, clinical and public education materials, and research resources. Agents covered included anthrax, smallpox, plague, botulism, tularemia, and viral hemorrhagic fever.

After the 11 September and anthrax terrorist attacks of 2001, vast amounts of information about bioterrorism were placed on the World Wide Web [1–3]. As investigators and scientists have sought to understand the details and implications of these events, government agencies and other organizations have published recommendations, educational materials, preparedness templates, and other information to help frontline clinicians.

As the Web increasingly becomes a mainstream publication channel, organizations use Web sites for primary information dissemination. However, practitioners seeking specific documents online may find the process a laborious one that requires sifting through search engine results and following links to sites of varying relevance. Although numerous sites have published pages or “subsites” devoted to bioterrorism-related clinical issues, many of them consist largely of links to other sites. Within sites, materials may not be organized intuitively, making them even harder to find. Our aim in the present article is to make the information search easier by summarizing essential information about content within a consistent framework.

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Methods

Site topic identification. To help define bioterrorism-related topics of most interest to Clinical Infectious Diseases readers, we conducted an informal peer survey of Centers for Disease Control and Prevention (CDC) colleagues who are involved in bioterrorism preparedness and response activities, to understand their information needs and favorite sites. We also reviewed records obtained from online discussion forums on anthrax recognition and management issues moderated during the anthrax crisis: one by the Emerging Infections Network of the Infectious Diseases Society of America (IDSA) (figure 1) and another by the American College of Emergency Physicians. We conducted searches on MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and the Health and Psychosocial Instruments citation databases for reviews of Web sites. Finally, we reviewed input from site users and stakeholders participating in the redesign of the CDC Public Health Emergency Preparedness and Response (PHEPR) site (unpublished data from CDC) (figure 2).

Figure 1
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Figure 1

Infectious Diseases Society of American Bioterrorism Information and Resources Web site as of 13 May 2003

Figure 2
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Figure 2

Centers for Disease Control and Prevention Public Health Emergency Preparedness and Response Web site as of 13 May 2003

Site identification. To identify sites, we browsed those mentioned in existing site reviews [4–10] and those listed in the top 50 results of searches using the terms “bioterrorism” and “biowarfare” on the Google (http://www.google.com) or Teoma (http://www.teoma.com) search engines. We browsed the sites we found for links to further sites. We checked the site list of organizations represented at the CDC's “Enhancing Effective Clinician Education for Bioterrorism and Other Emerging Infections: An NCID Consultation” event, held on 7 January 2002, in Atlanta, Georgia, for organization sites not already located (unpublished data from CDC).

Sites reviewed included those maintained by the federal government, medical societies (including society journal sites), and nonprofit academic institutions. Sites not reviewed included state and local health department sites and those managed by commercial entities. State and local health department sites were not included, because it is appropriate that clinicians would visit sites managed by their local agencies for region-specific information; therefore, such state-specific sites may or may not be comparable to sites with a national target audience. Sites managed by entities for primarily commercial purposes were not included, to avoid any possible conflict of interest.

Site review. Seven CDC reviewers who are involved in bioterrorism preparedness and response activities, including 2 content experts, independently reviewed the final site pool in random order. Two reviewers evaluated each site.

Each site was reviewed by gathering information on its location, sponsor, mission, content, potential usefulness during a bioterrorism event (as opposed to a nonevent or “readiness preparation” phase), ease of use, and adherence to accepted quality criteria and whether the site contained its own content or linked to that on other sites. Validation was limited to internal review by us.

The reviewers rated the usefulness of site content by topic on a subjective ordinal scale of 1–3, where 1 indicated the least amount of usefulness and 3 the greatest amount. Sites that received a 3 rating for a topic were rereviewed by the 2 content experts for inclusion in the present article. One content expert reviewed all review panel comments to identify additional relevant sites.

To determine a site's ease of use, we performed an assessment of its content structure and navigation system [11–13]. We examined the site's organization (e.g., by content topic), intended audience, and content format. Reviewers especially noted those sites whose structure was topical (e.g., organized by biological agent) or was based on known user needs, whose navigation was consistent and well cross-linked or cross-referenced, and whose link labels were clear and matched the content contained on the linked pages.

We checked sites that contained relevant content for general adherence to accepted standards of publishing on the Web [14]. Sites that did not include authorship or date information on individual pages or documents within their collections were noted. Although authorship can usually be inferred, the lack of posting date information makes it impossible to determine whether all materials are current.

The review panel's findings are presented below. The structure of the tables follows a precedent established in a previous article in this journal's Surfing the Web series [15].

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Results

Of >100 eligible sites that we identified for review, 79 were chosen as having target content of interest. Of these 79 sites, content from 43 was selected for inclusion on the basis of the review criteria described above. Subsequently, one site removed the content selected Journal of the American Medical Association (JAMA), and content from another (MMWR) was moved to another CDC site. Therefore, content from 41 sites is included in the present article. On the basis of review of peer survey and discussion forums, content was classified into 12 categories: general purpose and portal sites, clinically oriented biological agent information, laboratory-focused information, infection control—focused information, epidemiology-focused information, emergency contact sources, mental health and coping information, bioterrorism-specific news and updates, bioterrorism event preparedness resources, information for first-responder settings, clinical and public education materials and opportunities, and research resources and services.

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Discussion

General purpose and portal sites. The review identified several Web sites that either received mention by the panel for information that was usable by many audiences for multiple purposes or that included well-designed links to content on other sites. The Disaster Preparedness and Medical Response subsite on the American Medical Association (AMA) site (http://www.ama-assn.org/ama/pub/category/6206.html) has links updated for physicians, and its “News” section is kept current. The Association for Professionals in Infection Control and Epidemiology (APIC) site (http://www.apic.org/bioterror/) is a portal to resources on other sites that reviewers cited as having clear categorization of content by topic and detailed descriptions that accompany each link. The St. Louis University School of Public Health Centers for the Study of Bioterrorism and Emerging Infections site also offers a broad spectrum of content. The site is fairly easy to navigate, and the links are often annotated (http://www.slu.edu/colleges/sph/csbei/). Notwithstanding our potential bias, the CDC PHEPR site (http://www.bt.cdc.gov) was cited as an in-depth collection of information—especially information downloadable as documents. Forms, online training, and other preparedness tools are available for most clinical and public health purposes.

The FirstGov subsite “America Responds: Protect Yourself” (http://www.firstgov.gov/Topics/Usgresponse/Protect_Yourself.shtml) and the MedlinePlus Biodefense and Bioterrorism page (http://www.nlm.nih.gov/medlineplus/biodefenseandbioterrorism.html) focus on questions about bioterrorism issues from the public perspective. Each site aggregates links to content from the government, medical societies, and nonprofit organizations. MedlinePlus contains many links to government and voluntary resources. It is also a good source of news. FirstGov has a broader focus—terrorism of any type—and a smaller range of links on bioterrorism issues.

Clinically oriented biological agent information. Clinical information on biological agents is common on sites offering bioterrorism-related information and comes in a wide array of formats and levels of depth. Sources and their associated URLs are listed in table 1. (Clinical information that can be well adapted to educational purposes is discussed in the “Clinical and Public Education Materials and Opportunities” section.)

Table 1
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Table 1

Clinically oriented information.

Fact sheets and other brief overviews are among the most prevalent sources of agent information online. Resources covering agents such as anthrax (Bacillus anthracis), smallpox (variola major), plague (Yersinia pestis), botulism (Clostridium botulinum toxin), tularemia (Francisella tularensis), and viral hemorrhagic fever are common. In particular, the American College of Physicians—American Society of Internal Medicine (ACP-ASIM), CDC, St. Louis University, the Johns Hopkins Center for Civilian Biodefense Strategies, and the National Library of Medicine's Specialized Information Services post quick facts that easily browsable online for all category A agents; St. Louis University also offers them formatted in Adobe PDF format.

Sites with agent-specific information in clinical algorithms or guidelines include the ACP-ASIM decision-support tools for cutaneous and inhalational anthrax and for smallpox in both HTML and personal digital assistant versions; the ACP-ASIM site is also a good starting place for finding guideline-type materials on other sites. Frequently updated information can be found on the CDC PHEPR site, listed by agent and subdivided into topics, including recommendations and guidelines. The IDSA has posted “Clinical Pathways” flowcharts; the National Guideline Clearinghouse (a collaboration of the Agency for Health Care Research and Quality, the AMA, and the American Association of Health Plans) collects and summarizes guidelines; and the University of Alabama at Birmingham offers a differential diagnosis chart for category A biological agents.

More comprehensive descriptions of individual clinical agents also exist online. The IDSA offers “Medical Summary” documents, which are detailed clinical reviews with bibliographies of 4 category A agents. The Center for Civilian Biodefense Strategies at Johns Hopkins University provides consensus statements on each category A agent. Access to both of these sites is free of charge; many other sites provide links to or post copies of these articles.

Some excellent information targeting specific subspecialties is also available. The Armed Forces Institute of Pathology has published highly detailed descriptions of the pathology of anthrax and smallpox. The anthrax section is especially easy to use and includes case studies, whereas the smallpox site is formatted as a research paper, with links to images that pop up. The American Academy of Dermatology cutaneous anthrax slide set is large, thorough, and full of images. Finally, the Food and Drug Administration (FDA) bioterrorism page offers authoritative information on vaccine and drug issues. Information about emergency indication, approval of medications, and the proper use of diagnostic tests might be especially useful during a bioterrorism event.

Laboratory-focused information. Table 2 presents links to information useful to personnel in both public and private laboratories. Both the American Society for Microbiology (ASM) bioterrorism page (http://www.asmusa.org/pasrc/bioprep.htm) and the laboratory section of the CDC PHEPR site (http://www.bt.cdc.gov/LabIssues/) are significant sources of content. Protocols for agent identification, biosafety, and handling are available on both sites. Online laboratory training information is on the CDC PHEPR site, and links to other training resources are on the ASM site. Again, agents such as anthrax (B. anthracis), smallpox (variola major), plague (Y. pestis), botulism (C. botulinum toxin), tularemia (F. tularensis), and viral hemorrhagic fever are frequently covered in these resources.

Table 2
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Table 2

Laboratory-focused information.

Infection-control—focused information. Specific content devoted to infection control is scattered among many Web sites, and infection-control professionals may need to screen a great deal of content to find the most relevant material. Table 3 summarizes our panel's findings on this topic. Fact sheets for health care workers and the public that address infection-control issues are on the APIC site. Isolation guidelines and information about personal protective equipment are on the CDC PHEPR site (in the “Infection Control” sections on each specific agent's page). Infection-control guidelines are also on the Massachusetts General Hospital and St. Louis University sites; the latter is in the form of a concise table. The Premier Safety Institute (http://my.premierinc.com/frames/index.jsp) maintains a heavily annotated list of resources for infection-control professionals (most of which are found on other sites) under the “Disinfection and Sterilization” rubric.

Table 3
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Table 3

Infection-control-focused information.

Epidemiology-focused information. Table 4 lists resources of special interest to epidemiologists. Case definitions and recognition guidelines for major biological agents are on the CDC PHEPR site (in the “Surveillance and Investigation” sections on each specific agent's page). The IDSA has included thoughtful, brief summaries for 4 major agents as part of its “Medical Summaries” documents.

Table 4
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Table 4

Epidemiology-focused information.

Emergency contact sources. Health professionals should know whom to contact in the event of a suspected bioterrorism incident. Table 5 lists important resources identified in our review. The directories listed typically include complete contact information for individuals, offices, or laboratories.

Table 5
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Table 5

Emergency contact sources.

Mental health and coping information. Knowing how to help persons affected by a bioterrorism incident—including those directly affected, the general public, and the clinicians who care for those affected—is critical. Fortunately, resources exist online to educate clinicians, patients, and the general public. These resources are listed in table 6. The American Psychological Association maintains one such page at http://www.apa.org/psychnet/coverage.html. See particularly the “Coping with Terrorism” pages at http://helping.apa.org/daily/terrorism.html. Tips for Talking About Disasters (http://www.mentalhealth.org/cmhs/emergencyservices/after.asp) is a similar site maintained by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services. The site aggregates fact sheets and guides by audience and includes Spanish-language materials. Comprehensive materials for handling longer-term consequences of bioterrorism events are provided for specific target audiences by the National Center for Posttraumatic Stress Disorder at http://www.ncptsd.org/disaster.html.

Table 6
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Table 6

Mental health and coping information.

Bioterrorism-specific news and updates. Anecdotes from persons involved in bioterrorism response suggest that the public turn to standard media, such as television, for the latest news. There are, however, online sources for news or announcements of a specialized nature. Sources identified by our panel are listed in table 7. These include the CDC PHEPR homepage, with public-health—related updates and announcements; the FDA Bioterrorism site (http://www.fda.gov/oc/opacom/hottopics/bioterrorism.html), with news relevant to drugs and vaccines; the AMA Disaster Preparedness and Medical Response homepage; News: Topic: Bioterrorism (a collaboration of The New England Journal of Medicine [NEJM], and Harrison's Online); and Homeland Health (a collaboration of government, industry, and academic organizations). The last 3 sites highlight news on current bioterrorism-specific issues.

Table 7
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Table 7

Bioterrorism-specific news and updates.

Bioterrorism event preparedness resources. Preparing for possible bioterrorism events can be complex. Many sites feature templates, protocols, and other tools to help with the planning process. table 8 lists links to specific tools or to sites that aggregate preparedness information, such as the American Hospital Association site (http://www.hospitalconnect.com/aha/key_issues/disaster_readiness/index.html), which is specifically geared toward health care organizations. The “Readiness” section under “Hospital Readiness, Response, and Recovery” contains checklists, sample memorandums of understanding, and other tools for hospital readiness, response, and recovery and for development of infrastructure. A detailed “Bioterrorism Readiness Plan: A Template for Healthcare Facilities,” designed by APIC in collaboration with the CDC, is available at http://www.apic.org/bioterror/default.cfm#Readiness%20Planning, under the “Readiness Planning” section. The CDC PHEPR site consolidates strategies, plans, protocols, and other materials at national, state, and local levels on its “Preparation and Planning” page at http://www.bt.cdc.gov/Planning/. The Premier Safety Institute offers a variety of preparedness tools and special content from events that it sponsors on its “Emergency and Public Health Preparedness” subsite (http://my.premierinc.com/frames/index.jsp); from the homepage, choose “Disaster Readiness” from the “Quick Links” box in the left-hand navigation bar. Local agencies can find out what other agencies are doing at the National Association of County and City Health Officials “Bioterrorism and Emergency Response Plan” clearinghouse (http://bt.naccho.org).

Table 8
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Table 8

Bioterrorism event preparedness resources.

Information for first-responder settings. Practitioners involved in planning for possible bioterrorism events may need to understand approaches and guidelines specifically important for first responders, including those in the emergency department setting. table 9 contains a short list of resources.

Table 9
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Table 9

Information for first-responder settings.

Clinical and public education materials and opportunities. Materials that professionals can use to educate themselves and others (including the public) about bioterrorism issues are presented in table 10. Training opportunities, such as courses or lectures, are available online as Webcasts and self-study HTML modules—many with continuing education (CE) credits. There are several large collections of online training opportunities. A series of Webcasts on a wide variety of bioterrorism-related topics is posted on the CDC PHEPR site and on the University of North Carolina at Chapel Hill site. The Chemical Casualty Care Division (CCCD), part of the Army's Web site, has courses for CE credit. Despite the name, some of these courses address biological agents, and many are designed for both military and civilian practitioners. The University of Louisville School of Public Health has several online courses for medical doctor and nursing CE credit; one current offering, for example, is titled “Human Patient Simulation—Bioterrorism Attack.”

Table 10
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Table 10

Clinical and public education materials and opportunities.

Collections of reference guides and course materials such as slide sets and handouts that could be used to train others are contained in table 10, many of which were produced by professional societies and contain content tailored to particular specialties. For example, the ACP-ASIM has posted a series of lectures and self-assessment tests about anthrax and smallpox. The CCCD (click the “Training Materials” button on the top navigation bar) and CDC PHEPR (see “Training”) sites also contain material on this topic.

Research resources and services: bibliographies, journals, and newsletters. table 11 lists a selection of aids for researching bioterrorism topics. The National Library of Medicine's Specialized Information Services site provides a list of citations and other resources, listed by agent, and their “citations” links run preprogrammed searches of citations in MEDLINE and TOXLINE.

Table 11
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Table 11

Research resources and services: bibliographies, journals, and newsletters.

Many companies that produce medical publications have allowed free access to articles or related book chapters, including the Harrisons'/NEJM bioterrorism page (http://www.harrisonsonline.com/amed/public/amed_news/news_article/281.html). The CDC PHEPR site lists relevant articles from the Morbidity and Mortality Weekly Report (http://www.cdc.gov/mmwr/) and Emerging Infectious Diseases (http://www.cdc.gov/ncidod/eid/), under the “Referance” header within sections covering individual agents.

Caveats. Web site links change frequently. The content on the sites reviewed is current as of this writing, but given how often Web sites move or significantly change, some content may be outdated when the article is published. table 12 lists all sites featured in the present with their full names, publishers/sponsors, homepage URLs, and brief descriptions. If a site moves its homepage URL, readers can type the site name or publisher into a search engine to find the relocated site.

Table 12
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Table 12

Web site/page summary.

Although we reviewed sites for content, we cannot authenticate adherence to generally recognized guidelines for the proper collection, attribution, and consent for reproduction of information posted. Finally, although we can point readers to bodies of content, we cannot review or evaluate individual pieces of content for scientific accuracy. Readers should consult published reviews concerning techniques for evaluation of Web sites for quality and accuracy [14].

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Acknowledgments

We thank Daniel Jernigan, Scott Fridkin, Michael Bell, Lynne Sehulster, and Lennox Archibald in the Division of Healthcare Quality Promotion; Ronald Cunningham from the American College of Emergency Physicians; Laura Liedtke and Larry Strausbaugh from the Emerging Infections Network of the Infectious Diseases Society of America for their assistance; and Victor Yu for his helpful advice during the preparation of our manuscript.

  • Received December 12, 2002.
  • Accepted December 27, 2002.
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  1. Clin Infect Dis. (2003) 36 (11): 1458-1473. doi: 10.1086/374560
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